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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DELCARATION
<br />I h.r.hy dltn trnd.r F.alry ol Jr4ury lhdr I dr c\cmtr ft)m rhc Conlrucron l,i.cnsc I-!w lor rhc lnlbw'nt rcrc,n (S..7011 5
<br />Busi"cs aBr Pdc$ion Ciic): Any City o, Counr, whrch lcquias r Irrmn b con{dcr. ,lrcr. inrrorc. dcfr)lFh or rcp.ir lny
<br />nructur. prirr t' ih is\rafre. nl$ rcqrnc\ $c,mncanr tur such p.m[ k! Iilc r sitncd srdrcnrnr lhar lE or sic is li(n{d nururr
<br />k' rh. pmvri,)trs ol rnc Cr,trr.aukni Liccn\cd trw ((rhapic. ,. Conrnrncm! wnh Srron 700(r or Drvmon J .l rhc Busincs an'l
<br />Px'lcsn,nr CoJc)or rhdr h. or shc s.xcntfl (hcrcfoh rJ rhc hrn! ntr rhc.llclql cicmtrion. Any vn'hrnnr Dl Seriod 70ll 5 by rny
<br />!!fli.. 6r aI'(mr $rhjels lhe arrolica b 0.ivilpcnrllyolnor morc rh3n livc hunJr&l doUrs (5500).
<br />_I- as ownc, oa rhc ptuFny, or hy cnpn,ye\ *irh w,!cr !s rh.t snc conEtrsrlnnr. will!o rhc *o.k anJ rh. {turm n nor
<br />!iL:rl.J oro,Lrcd lor salc (Sa.7044. Busincsand Al,ttsil)"s C( c I hc O,nlra&tr's LM.s. La* drs nor aPFly l. an owrcr oi
<br />rhc F)pcdy wh{J $oiusor mlrt)Es rh.d)n, ,rl who d(s such M'It hmsclfor hcncll or rhNugh hk orhero*n cflploycc\.
<br />pruv cd rhrrnrh nDn)rmnk c nn inlcRl.rl or oltaBJ lor sk. Ii bwcvcl rlE lxilliry or iq{ovcBd is $Ll withinonc rd
<br />.l con[,.rin. rh. Own$ Bu ds will havc tlE b{ntcn ol l]nrvr3 (h.l hc or shc did nor huil] or impn)rc rhc nmFny for rt puqrM of
<br />l, rsownci.l rhc potFdy, rn.rchtrNtly conrrdrg rirh lt.n\cJ c.ntdrh\ n'..tr{flr.r rh. pn*cr (Scc. 70,14. Busincs
<br />. PnnL\<hn Cod.: Th. Conr&ttr s Li.cnsc Lrw docs r.r .pt'ly b ! owtrc!oipoF.dywhohuild\orimpiov.srhcrcon.
<br />rn'l who.arnrc(rslorstr.hpojccrswirhacro a('(r lircnscJ NnMnr ro rhc (i, ra.u's Lic.nsc Lo* ).
<br />_l lhercnpr utulcr S*tn,n_, B. & P.C. ror thi Hso
<br />Iyll86E8EtlMrENlAro!
<br />UECIABAIII}!
<br />I hcrcby atltm uklcr Fnrltyol pcrjury orc ol lh. tollowhs Jal.,arbns:
<br />-Ihrvc.J
<br />will mainlalr a Ccrl rlrllc .t Conscnt b Scllr$uN tu workeB ompcnsrrn,n. rs pmviJcJ tur $y Sexon r?Lx) ol th.
<br />litrtr Ciile. tor rhc penomNc of rh. w.rk for which rh. p.mn t s\ucJ
<br />I hnv. rid wrllmrintr q.rkcra .o nrnc.s a I ion rnsunh_c, ds rcqut'lhySernr.lT0Oolth.lll$rCodc,ntr[cncriinn ccof
<br />lhc qrk lirwhrhth$ ncmnr is nsued. Myworkcr'i,mmneri,'n i'rurrnlc.rrirr JD.] tuhvIrns. Fuyr\'-Sia\e Coyn z-\:Lo,49A,oL \
<br />.N'l ltrk! ot) k, !trtr hrtrJRl rh.!\ rJ ,s{,lr,, m turdrru,tr t) rhc cod uf conpcnnbon. drmscs as prcvi,lcJ ftt lhc
<br />ryi'jrdi""Ua
<br />I lErcby alinm unlcr I'cnaltyol Frjury rhar I an liLcnsn ondq pn,visth olChnprc.9 (onrmncinS wilh Setion rfix)) oIDilhion.l
<br />ol rhc Burin.sr anJ ProLssirns Codc. ari my tccns. is in txl nrcc !n] ct'tcur.
<br />,C-@ qb6?q3
<br />,r'-t-Cov r6lielflect
<br />dIBIISAXTPE!:Idf,AIIAN
<br />I lrtbyafmunJ.r p.nrlry.fF jury onc ofrh. tallow,n8 Jelxr ionsl
<br />Dcfrnnn,n Pcrnih-Aihcdo! Norifi.aron F.dchl R.lularions (T lc 40. Pan6)
<br />_R.qutcd lrtr.r ol NorilMrion
<br />_l ecdililhd th. Ldorlr+ul.lklns rcEr,irng rsbcsor rcnn,vrl !!. nor applicrhk t, rhn ttu cci
<br />ill lqrirylhir lhJvc rc r[n iml (rl drrcrhrrrhoJrNc'nnn Ia!rL\r,LonryqfhallC[yrtrJ(in'nty
<br />oiJiJrn..s rnJ Slrrd I r!\ rchring iUinf condnknon. ml hcrhy 3urhntrc rctlrc\c dnvcsofrtusCitya Cotrnryt,cnr$ur$nrh.
<br />I ru,vc Nnrn,rd pruFny nn
<br />A pplienl 0r ,1A.rt SiEtr{lu
<br />q,n
<br />c
<br />uW .L-3-20
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathinq -1"%V-+n tl?T
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />I
<br />FINAL I qnoTo I\hal Yt >4-x6
<br />Certificate of Occupancy T I
<br />Notes Remarks ElC ,b Ja r',JI}-rw AT l{dA h
<br />BUILDING. INSPECTOR RECORD
<br />s
<br />Sublloor/VenUl nsu lation
<br />Flood Zone Certil.
<br />_lccdilyrhdn,rhcp.r,i,rnunc.olrhcworkturwh,chrhnl}.rm n '\rcJ I dull n.r cmpl,,y rny pcr$n i. uymrncr
<br />$ N(obcconr sublcd ro rhc w)dcr' u.nlI).nsaron laws ofcalibmia..n'l a8rc rhrr l sk,uld b.com \ubicd k,rhc
<br />worftcs' ..mp.ns!ri'. pn)v6 tr,ns ot ssnon J?(x) ol rh. Ijhtr c,rlc. I \hdl. lodhw h eonPly {,lh rhosc l,ruvsons.
<br />IVARNIN(; Eailuc ro s.r'c ktrkcrs u{nlllc s!ri,,r lovcrrrc ]\ u lariul. dDJ shall subje.r rn cnrploys b cnmral Fnr[a\ MJ
<br />collralJclloN.tsNuNcl(iElrl
<br />I h.rchyalllrnu cr p.nahyolp.iJuryrl r rhdc is a coninrrtr)n htrJnB a!.ncy liJr rhc ocdnm.u. ol rhc *oA ,nr whrh rhls rcmnr i\
<br />issrd(Scu. (r97,Crv. C )L' r,'\ Nrn*
<br />Lcn lca' A,l lrc*:
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